NHS trusts and foundation trusts

An NHS trust is a public body that runs hospital, mental health, community or ambulance services in England and employs the staff who deliver them. A foundation trust does the same work with more independence from central control, plus a membership and a council of governors. For most staff the label makes little difference: both use Agenda for Change pay, the NHS Pension Scheme and the same national terms.

Types of trust

Trusts are grouped by what they do, and the type shapes the jobs on offer.

Acute trusts run hospitals with emergency departments, theatres, wards and outpatient clinics. They are the largest employers and recruit across almost every profession. Some are teaching hospitals with medical schools attached, and several run multiple hospital sites.

Mental health trusts provide inpatient units, community mental health teams, crisis services and often learning disability services. Many also run community health services in their area.

Community trusts provide district nursing, health visiting, school nursing, therapies and community hospitals. In some areas an acute or mental health trust runs these services instead.

Ambulance trusts cover a whole region for 999 response, and most also run NHS 111. Jobs range from call handlers and emergency care assistants to paramedics and control room clinicians.

There are also specialist trusts, for example in cancer, orthopaedics, children’s services or cardiothoracic care.

What makes a foundation trust different

Foundation trusts were created to give well-run trusts more freedom. They answer to a council of governors, partly elected by public and staff members, as well as to national regulators. In theory they can keep surpluses, borrow and set their own terms for staff.

In practice the gap with ordinary NHS trusts has narrowed. National financial controls apply to both, and almost every foundation trust uses Agenda for Change. The differences you would see as staff are these:

• you can usually join as a staff member and vote for staff governors
• the trust publishes governors’ meetings and annual members’ meetings
• the board may make some decisions locally that an NHS trust would need national approval for

Pay and terms across trusts

Nearly all trusts use Agenda for Change, so a band 5 post pays the same basic salary in any English trust: £32,073 at entry from 1 April 2026, rising to £39,043 at the top of the band. Pay can still differ between trusts in a few ways:

Element	Varies by trust?
Basic band salary	No, set nationally
High cost area supplement	Yes, by location (inner London, outer London, fringe)
Banding of a specific role	Yes, through local job evaluation
Recruitment and retention premiums	Yes, local decision
Bank rates and incentive payments	Yes, local decision

Banding matters most. Two jobs with the same title can be band 4 at one trust and band 5 at another, depending on how the job description was evaluated, so read the band on the advert and not just the title. More on bands in NHS Agenda for Change pay bands.

Annual leave under Section 13 of the handbook is 27 days on appointment, 29 after five years and 33 after ten years, plus 8 public holidays, and previous NHS service counts towards those steps at any trust.

Who runs a trust

Every trust has a board of directors: a chair and non-executive directors appointed from outside, and executive directors such as the chief executive, medical director, chief nurse, finance director and director of people. The board meets in public several times a year and publishes its papers, which include workforce figures, vacancy rates, sickness absence and staff survey results.

In a foundation trust the council of governors appoints the chair and non-executives and holds them to account. Staff members elect staff governors, who are a channel for raising concerns about staff experience with the board. Below board level, trusts are organised into divisions or care groups (surgery, medicine, women and children, for example), each with its own management team. Most decisions about rotas, recruitment and budgets for your ward or department are made there.

Mergers and group models

Trusts merge, form groups with shared chief executives, or transfer services between them. When a service moves from one trust to another, staff transfer under TUPE with their terms and continuous service. Mergers can lead to consolidation of back-office roles such as HR, finance and IT, which is where most restructures and redundancies in trusts happen. Clinical posts are usually redeployed or moved.

Choosing a trust to work for

Trust-level information is public and worth reading before you apply. CQC inspection reports show ratings and comment on leadership and culture. The NHS Staff Survey publishes results by trust, including how staff rate their managers and whether they would recommend it as a place to work. Board papers, published online, show vacancy rates and financial pressure.

Conditions also vary by department within a large acute trust, so ask at interview about staffing on the specific ward or team, and whether it relies heavily on bank shifts. If you are already in the NHS, moving between NHS trusts explains what carries over when you change employer.